Nursing homes are rapidly becoming a dominant setting for death; 25% of all deaths occur in nursing homes and 35% of all elders over the age of 85 die in nursing homes. By 2020, 40% of those over 65 will die in nursing homes. There is a growing body of empirical evidence which describes problems with end-of-life in nursing homes such as avoidable weight loss, dehydration, pain, pressure ulcers, poor quality of life, and family strain. Improving care to this vulnerable population has become major public health concern. Interventions in nursing homes frequently fail and have rarely considered organizational attributes that influence a nursing home's ability to develop and maintain improved practices. Therefore, the purposed study will examine key organizational structures and processes (leadership, communication, teamwork, palliative care) and their impact on the quality of end-of-life care for dying residents and their family members. The proposed study has three aims: 1) Determine the influence on palliative care of communication, leadership, and teamwork; 2) Examine the associations among structure (staffing), non-clinical (communication, leadership, teamwork) and clinical (palliative care) care processes and quality of end-of-life care; and 3) Explore Unruh and Wan's expanded structure, process, and outcomes model in the context of nursing home palliative care. A prospective, correlational design guides the proposed study. Data will be collected from 100 randomly selected Kansas nursing homes. Data reflecting staffing variables and clinical and non-clinical processes will be collected from direct care staff at baseline and follow-up. Data reflecting quality of end-of-life care for dying residents and their family members will be collected prospectively from family members following a resident's death. Quality of end-of-life care is reflected by facility process indicators: the number of hospice referrals, feeding tubes, hospitalizations, and advance directives; and resident/family outcomes: resident/family centered care, family satisfaction with care, family caregiver strain, resident symptom distress, and resident preferences honored. Analyses include generalized linear models, two-level linear mixed models, and two-level structural equation modeling. Findings from this study will drive the development of interventions aimed at differing levels of communication, leadership, communication, and palliative care to improve end-of-life care for nursing home residents. [unreadable] [unreadable] [unreadable]